Summary:The American Association of Naturopathic Physicians (AANP), the national professional association for the nation's 4000 naturopathic physicians, celebrated its 25th anniversary conference in Portland, Oregon in August. This report offers snapshots of the profession at a challenging juncture. Included here are: perspectives of modern elders Jared Zeff and Joe Pizzorno; budget issues amidst a declining economy and advancing public interest; research report from Dugald Seely and Patricia Herman on the most useful whole practice outcomes the profession has developed; election of Michael Cronin, after a battle, to AANP president-elect post; announcement of Bastyr University's plans for a new California campus; clinical leader Mona Morstein's challenge to keynoter Josephine Briggs, NIH NCCAM's director; House of Delegates action; kick-off for a new Naturopathic Physicians Research Institute led by Carlo Calabrese; meeting of senior editors on the Foundations of Naturopathic Medicine project; and some commentary.

Celebrating 25 years

During the week of August 8-15, 2010 the American Association of Naturopathic Physicians celebrated its 25th Anniversary in a series of business meetings, educational sessions, social events and dancing. The title was Celebrating the Foundation of Medicine. For the modern naturopathic
medical profession, the Portland, Oregon location made the theme
particularly fitting. Portland is the home of the mothership of the modern profession, now called National College of Natural Medicine (NCNM). Over 50% of North America's roughly 4000 licensed naturopathic doctors are NCNM graduates.

One presenter at the AANP conference, Carlo Calabrese, ND, MPH, executive director of the new Naturopathic Physicians Research Institute (see below), framed the profession's size this way: "NDs represent roughly
1% of the
nation's physician-level practitioners who are trained to serve in
primary care roles." The NDs believe their broader inclusion could help meet the
nation's needs in that area, as well as help model a new form of primary care. Here is a report of some impressions on the maturation of this profession in this celebration of the 25th year of their professional association.

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1. Presentations from the two of the modern elders, Jared Zeff, ND and Joe Pizzorno, ND

Zeff: Known for nature cure

The bookends to the conference's educational content were keynotes from Jared Zeff, ND, and Joseph Pizzorno, ND. Zeff is closely associated with the historic "nature cure" orientation of the profession. Pizzorno is known for promoting a "science-based natural medicine" approach which has, due to the preponderance of research in natural approaches being in the area of natural products, tended to promote the therapeutic focus on natural pharmacy as a first line of treatment, a direction sometimes derided as "green allopathy."

In Zeff's talk, he presented the naturopathic principles, formally adopted through a 1987-1989 process which he co-led with Pamela Snider, ND. These Zeff linked to a paradigm shift in
science and philosophy that he believes is increasingly coming to the fore in conventional medical thought if not yet in practice. He spoke of the vis medicatriz naturae, the healing power of nature, a concept he places at the center of naturopathic medicine. Zeff urged his profession to continue working on characterizing the nature of the vis,
including examining both vitalistic views and materialist explanations of this healing power.

Pizzorno: Known for science based natural medicine

Pizzorno, perhaps the most visible modern leader of the profession, opened with the statement that "the future of naturopathic medicine is naturopathic medicine." He advanced a view that the profession's optimal future is not in taking on a functional
medicine model, or or biomedical model or in merely pursuing integration. Rather, Pizzorno urged his profession to go more deeply into its own values and meaning to human health. He noted the expansion of conventional drug treatment in the legal scope for NDs in many states and questioned patterns that he sees emerging. In his view, the NDs may be drifting toward
using "higher force" agents prematurely, when agents with fewer adverse effects might be in better accord with the profession's concept of a proper therapeutic order. He underscored that the profession's promise is to "treat people by making them well," arguing that at this point the profession and its practitioners are not engaged at the depths that they need to be in this core purpose.

Comment: I received notes that I converted into these synopses from individuals who attended. I unfortunately missed Zeff's kick-off talk due to a required meeting in Seattle. Pizzorno's talk, called simply the Foundation for Tomorrow's Medicine, was on my schedule but I missed it when I got caught in the foundations for my own health care, namely an informal qi-gong session with a half-dozen friends led by Kevin Davison, ND, LAc in the backyard of the home of Rick Marinelli, ND, LAc where I was staying for the conference. I like the focus on core principles that came through in both of their talks, and in my session. I suspect that both Zeff's and Pizzorno's views were significantly influenced by the pre-conference senior editors' retreat of the Foundations of Naturopathic Medicine Project, noted below.

Howard: 260% revenue growth since taking over

2. State of the organization: Shrinking budget, increasing public interest

In a general membership meeting, the AANP reported a roughly break-even
2010 budget that is 3% less than 2009, at $1,615,176 in revenues. This is 261% higher
than 9 years earlier when present executive director Karen Howard took on leadership of the organization. Revenue issues were front and center as both exhibitor and attendee revenues were off projections for the
conference. The prior year was portrayed by treasurer Corey Resnick, ND as "a very challenging year" in
which expenses needed to be reduced by nearly $250,000 to keep from further writing down AANP's accumulated reserves. Present year
income is also off. Yet meantime, the AANP website has seen a 212%
increase in hits on the website, members in some 2 dozen states are pressing for licensing and new graduate realities are begging for more acceptance as primary care and inclusion in federal loan payback programs.

In a short talk to members, Tim Birdsall, ND, a current NIH NACCAM
member, pointed to 3 macro changes influencing the profession's future: the
depressed state of the economy; the "opening of a crack" of opportunity
at the federal level via the Obama-Pelosi health reform legislation; and
the demise of the Clayton College of Natural Health.
(The latter has been a source of tens of thousands of mail-order "ND"
degrees over the past 25 years and has funded opposition to the
expansion of state licensing for naturopathic physicians beyond the
current 15 states.) Birdsall's sentiment was of a sober sizing up of shifting realities.

Briggs: Plenary focused on product research

3. Keynoter Briggs chided for not focusing on whole practice research

More than one speaker in the 20-segment research track commented on the
growing interest of AANP members in research led by naturopathic doctors. Roughly 60 to 100
participants - still a fraction of those in attendance - typically chose the track. This is up from just 5-15 attendees a few short years
ago. The conference included a plenary presentation
from NIH National Center for Complementary and Alternative Medicine
director Josephine Briggs, MD.
Briggs' talk was a version of her stump speech, focusing largely on single agent herb and dietary supplements,
agents that naturopathic doctors use in a mix with other approaches in their whole person-oriented practices. After Briggs finished, questioner Mona Morstein, ND,
well known inside the profession for her
work as clinician-administrator of the main internet discussion group for licensed NDs,
challenged Briggs:

"As a naturopathic physician, I am disappointed. The
methodology (in single agent trials) has nothing to do with the way I practice. Have you
considered that this mechanistic model you have is all set up [to have
negative outcomes]?"

Morstein: Briggs' talk missed the mark

From informal discussions post session, Morstein seems to have captured a sense of many in the room, although some found Morstein's directness ungracious.

Comment: I was surprised that Briggs'
presentation didn't speak directly to the interests of these whole
person-oriented practitioners. Briggs' AANP talk would have been an ideal
setting for her to directly deliver her perspective on whole practice, outcomes-oriented, pragmatic research. The setting would have been particularly appropriate given the recommendations from the AANP and the naturopathic council of colleges on NCCAM's new strategic plan. Interestingly, Briggs could have spoken directly of
two recent NCCAM-funded projects involving naturopathic physicians as examples. I was reminded of these by NCCAM
program officer Wendy Weber, PhD, ND, also in attendance. One, on naturopathic adjunctive care for breast cancer patients is led by Leanna Standish, PhD, ND, LAc and is noted here. The other, on diabetes with Ryan Bradley, ND, MPH in leadership, is mentioned here.
The presentation was a missed opportunity for cutting the alienation
that many NDs feel toward NCCAM's historic focus on basic research and single agent trials. Too bad.

Healy: Soeaker for a tough House session

4. House of Delegates: Renewed strength, but work product mostly invisible

The AANP's House of Delegates, under the leadership of Helen Healy, ND and Kevin Wilson, ND,
is slowly taking on a more visible role with the organization after a
period of quiescence. Two new specialty societies were approved, one related to naturopathic pediatric care and
the other to post-graduate residencies. A new code of ethics was
adopted
provisionally while an attempted revision of the AANP's standards of
naturopathic medicine position paper was sent back to committee. The
AANP does not, at this time, share the position papers that the House
has passed with the
public. This practice was a source of significant internal debate during the
House meeting. A small faction that seeks to keep them out of the
public eye prevailed on a procedural issue. The House action, described by various sources as sometimes fractious, also included adoption of new provisional
policies and procedures on how to move position papers through the
House.

Comment: I have been aware of the
position paper issue for some years. Some in the profession fear that
one or more may be used against the profession in a licensing effort.
My own view is: Why take a position if it's not public? Healy, who
supported making the positions public, shared a definition of position papers during the meeting: "Position papers are formal
statements on an issue of importance. Through the position paper, you announce
to the world your position on a particular issue or difficult problem as the
foundation for proposing solutions to the issue or problem." The NDs won't move far if they are afraid to let their differences with conventional medicine, as well as their common cause, be known.

In what was the AANP's first contested election for the presidency in the history of the organization, Michael Cronin, ND was selected as president-elect by a 60%-40% margin. Cronin, a
founder of the AANP and co-founder and founding president of the Southwest College of Naturopathic Medicine, ran as a candidate for change. Cronin challenged a highly regarded
candidate with multiple contributions to the profession who was selected to run by the current administration. Pre-conference, an election
battle raged on a 2000+ member ND discussion forum and via email lobbying. Past-presidents and
current board members publicly endorsed each of the candidates. Cronin
took the position that the AANP could do more than it has done with its
resources to promote new licensing and to move NDs into federal policy. He also urged a more significant focus on scientific affairs
and particularly whole practice research and an approach that might be conducive to more volunteerism from the profession. Those who were familiar with
the heady years of venture capital in complementary and alternative
medicine in the late 1990s may recognize Cronin as the former director
of integrative medicine for the network of MD-led American Whole Health clinics. Cronin's term will begin in January 2012 after that of current
president Carl Hangee-Bauer, ND, LAc ends.

Comment: Following the banquet and awards dinner of the conference, I asked attendee and Integrator columnist Michael Levin
for a short synopsis of his sense of the AANP at this moment in time.
After thinking for a good while, Levin responded: "Divided and
unfocused." Notably, a post-conference AANP blog post on the conference written by Howard did not mention the membership's choice of Cronin as president-elect. There was scarring in the campaign. Competing views of the association's direction are on the table. Naturopathic doctors profess belief in the concept of a
healing crisis. The present struggle may rightfully be a sign of professional maturation. Perhaps this moment will be one from which the AANP
emerges with new strength. I hope so.

Disclosure: As a past colleague, longtime friend and presently close associate of Cronin (see #9, below), I followed developments closely. Despite respect for his opponent's considerable accomplishments, I believe Cronin's win will prove best for the organization.Vamos a ver.

The research track, moderated by Wendy Weber, ND, PhD, included a report that some in the field immediately called a "game-changer." Preliminary results from a randomized controlled pragmatic trial of the whole practice
of naturopathic medicine for Canada Postemployees
with elevated cardiovascular risk
found treatment by integrative naturopathic doctors to be both
effective and cost-saving. The research team, from Canadian College of Naturopathic Medicine, led by Dugald Seely,
BSc, ND, MSc and economist Patricia Herman, MS, ND, PhD concluded that the naturopathic interventions generated a "total societal cost saving" of $1025 per employee. Seely reported a favorable change in the incidence of metabolic syndrome, a significant diminution of average cardiovascular years and positive outcomes on a range of self-reported measures. The study is reported in detail in this Integrator article. Noted Herman: "If we examine only
direct costs, it looks like the cost of naturopathic care per unit
reduction in the risk of cardiovascular disease is somewhere between
that of aspirin and that of statin drugs."

Comment: I am among those who view this research, and more like it, as the key game-changing levers needed by the naturopathic profession. As argued in the Integrator feature on the research, the methods for researching this whole practice,
individualized treatment are a model for all integrative practitioners,
whether integrative MDs/DOs, broad scope DCs, AOM practitioners or
other multi-modal care-givers for whom reductive trials fail to capture
their practices. The model provides critical information for healthcare decision makers. This would appear to be just the kind of outcomes research US Senator Tom Harkin wanted when he laid out the mandate for NIH NCCAM. That we haven't seen more of this work makes me wonder, from time to time, if there are those who simply don't want to see whole disciplines elevated. Hopefully we'll see more of this kind of research soon. Kudos to the team, and especially Seely and CCNM president Bob Bernhardt, BSc, MEd, LLM, PhD for fostering and nurturing the relationship with Canada Post and the Canadian Union of Postal Workers.

Dan Church, PhD, president of Bastyr University, chose an alumni reception as the event to announce a major move by his institution. Bastyr plans to open a branch campus in California with the first classes to begin as early as fall of 2012. In a subsequent news release, Church noted:

"We are thrilled to expand the University's presence and provide
prospective students greater access to Bastyr's widely acclaimed
naturopathic medicine program. We are grateful to the
California Naturopathic Doctors Association (CNDA), which has worked
closely with us to determine the best approach to our expansion. We
believe that a Bastyr University campus will benefit both the
naturopathic medicine community and the health and well-being of the
citizens of California."

Barker: California ND group partners with Bastyr

The release called attention to the fact that NDs are licensed to practice as primary care doctors
in California. Bastyr positioned their move as an effort to help meet a need for
such practitioners in the state. Simon Barker, ND, CNDA president, is heading up planning for the California NDs with whom Bastyr has signed a memorandum of understanding on the move. Sources close to the planning reveal that the not-yet-disclosed location is likely to be in the LA basin. Church noted that an anonymous donor has indicated plans to offer an undisclosed, substantial donation so that the move will not be borne by current student tuition.

Comment: A move such as this has been long discussed and explored. There is great potential benefit and definite risk to the school and profession in the move. California is the source of over a third of the students to all 3 of the ND programs in the West (Phoenix, Portland and Seattle). What impact will this branch campus have on enrollments elsewhere? The bigger question regarding this move is whether starting a new program is the best gambit, given the known, struggles of current graduates of Bastyr, and elsewhere, in making a go of it once they leave school. Many finish with $150,00-$250,000 of student loan debt yet the healthcare system is not yet very interested in employing them. For 20 years, I have joked to NDs, somewhat sardonically, that they have just enough societal and governmental recognition to go into debt, just not enough to get out of it. Average debt has tripled in those 20 years. The matter is no longer one for joking. Will a California campus for Bastyr be a positive factor in changing this reality?

Snider: Leading the Foundations process

8. Foundations of Naturopathic Medicine Project moves forward

Since 2005, a quietly growing influence in the profession's development has been the Foundations of Naturopathic Medicine Project (FNM), led by Pamela Snider, ND. Originally a book project with Elsevier, Snider and her senior editor team, which includes both Zeff and Pizzorno, have used the project as a deep exploration of both the roots of this healthcare option and the modern science that supports it. In a collaborative project to capture the profession's history, Snider's team rolled out a time-line on the exhibit hall walls, inviting attendees to add significant dates and actions. Snider, an Integrator editorial adviser, explained: "The timeline is built around the concept of professional
formation and benchmarks of emerging professions, including regulation, education, accreditation and codification of
knowledge." The timeline, to be published as part of the Elsevier text, traces the
evolution of these processes plus association development, mainstream
integration and collaboration, and public policy involvement.

The Foundations project also convened a senior editors' retreat at the conference, involving international leaders from Canada (Don Warren, ND, DHANP), England (Roger Newman Turner, ND, DO), Australia (Stephen Myers, PhD, BMed, ND) and the United States (Snider, Zeff, Pizzorno and AANP founder James Sensenig, ND). An e-exchange on the value of their meeting provoked these reflections:

Myers: "We had an intense discussion on the
interpretation and articulation of the fundamentals of naturopathic medicine
that reached an international consensus. In reflection you realize that history
is made in such moments."

Sensenig: "This international editors panel reaffirmed classical principles
that have been observed over many millennia and guide the healing art."

Newman-Turner: "Thanks to the technology of webcam, I was pleased to be able to
participate fully in the meeting of the Senior Editors in Portland at which we
were able to reach some important policy decisions regarding the style and
language of the Foundations of Naturopathic Medicine textbook - decisions that
will enhance the clarity and wisdom of naturopathic medicine for the future."

Warren: "It was an awesome experience
sitting around a table with individuals who have taken many leadership roles in
the profession with close to 200 combined years of naturopathic medical
experience. The significant outcomes of such a meeting and lively
interchange will ripple on for years to come."

Zeff: "To sit around a
table with Roger Newman Turner, Stephen Myers, Don Warren, Joe Pizzorno, Jim
Sensenig, Pam Snider, and Erica Kubanek [a student support person], and talk about naturopathic
philosophy, its finer points and their best articulation, was perhaps
the high point of my year."

Pizzorno: "This textbook promises to be the most important book about health and healing written in the last 100 years."

Snider shares that the book is due for 2011 submission to Elsevier with then 6-9 months before publication in 2012. The long gerstation period, says Snider, is by design. The textbook was to be written
via a series of retreats and symposia. (See Integrator article on one symposium here.) The Portland retreat was the second. "The
roll out of the book," Snider adds, "will include an international symposium and call for
abstracts from the profession. This will include thought leaders from other
health care, environmental and scientific disciplines to critique, hone and refine naturopathic medical thinking."

Comment: Snider shares that "what's unique is the
profession is not just writing a book, but is examining key issues in its development." The forecast from Pizzorno, a former member of the White House Commission on CAM Policy, member of his local Board of Health for his county, past president of the Institute fior Functional Medicine, is jaw-dropping. Might a growing mass of now 4000 physicians, committed to whole person treatment and a holistic philosophy, working together to renew/recreate healthcare, produce such a volume? Get the book out so we can all participate in the dialogue and see the outcomes of this labor!

Calabrese: NPRI will explore the way NDs practice

9. Formation of Naturopathic Physicians Research Institute announced to "explore the way we practice"

The conference marked the kick-off of a new not-for-profit organization in the field, the Naturopathic Physicians Research Institute (NPRI). The organization was created to focus the profession on "in-practice and whole practice research" according to founding executive director, Carlo Calabrese, ND, MPH. Calabrese has promoted an outcomes focus in naturopathic and integrative practice research for nearly two decades, including during his recent term on the NIH NACCAM. The NPRI website banner states: Exploring the Way We Practice. Then the mission: " ... to stimulate,
organize, fund, conduct and disseminate research on the clinical
practice and outcomes of naturopathic physicians in order to improve
practice and the health of their patients and communities." Key tactics include use of the 90 doctor Naturopathic Physicians Research Network, organizing research education to deepen awareness of whole practice and outcomes methods, promoting reports on individual cases and case series, and organizing institutions and practices for collaborative exploration of electronic medical records, where available.

Comment, and Disclosure: As many Integrator readers will know, from 1983-1993 I worked in the leadership of the re-emergence of the naturopathic profession, first at Bastyr then as the AANP's firts paid executive director. Those were early years of renewal. One significant area of my interest in both positions was promoting research and in particular an outcomes-focused research agenda. When my friend and colleague from those years Michael Cronin, ND, the profession's new president-elect, asked me if I wanted to join him in founding a new organization to do just this, I broke all vows to self and spouse and said yes. Helping empower Calabrese and the team he has assembled (which includes Seely, Herman, Birdsall, Standish and Bradly, all noted elsewhere in this report) to excite interest among practitioners in exploring the way the practice is good volunteerism.

My postulate is that NPRI is at least a "two-fer." On one hand, NPRI promotes development of the kind of data that can shift opportunities for new graduates with their awful debt load. The Seely-Herman report, noted above, is one example. Second, this focus can potentially break down the alienation many naturopathic doctors and other integrative practitioners feel from a typical, reductive research agenda in which they cannot see their own practices reflected. I hope the naturopathic profession will step up to this, as I hope other integrative practitioners and their organizations will embrace parallel missions. Calabrese likes to remind me that the core agenda is actually about practice improvement and, as the NPRI mission states, "improving the health of patients and their communities." Got any funding ideas?

A recent blog post on the conference from Howard, the AANP executive director, noted the following physicians who were honored at the conference, together with the association's corporation of the year. The copy, except the parenthetical sections and the links, is from Howard's posting:

Naturopathic Doctors News and ReviewsCorporation of the Year, for giving voice to the entire naturopathic community in a publication known for excellence. (Razi Ann Berry is publisher and David Tallman, DC, ND editor.)

Susan Delaney, recipient of The President's Award, whose presence in
her state work and her mentorship deeply reflects the principles of
naturopathic medicine.

Christine Girard, Physician of the Year, whose visionary work will
continue to inspire for years to come, especially for the students to
whom she dedicated her award. (Girard, a vice-president at Southwest College of Naturopathic Medicine, was also recently honored as the featured interviewee for Alternative Therapies in Health and Medicine.)

Congratulations, all.

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Overall Comment: The little profession that could. I've sometimes heard the naturopathic profession described this way. In Zeff's talk, he recalled counting ND licenses in the half dozen states that still had licensing in the early 1980s. He found about 240. The profession was very nearly wiped out by the emerging legislative practice in the late 1970s of sun-setting old and unnecessary boards and councils. It has come a long way since but still remains little more than a homeopathic dose relative to conventionally-trained colleagues. The profession's contributions have already been many, not the least of which has been offering a high standard of integrative medical care to hundreds of thousands of individuals each year. If the Foundations of Naturopathic Medicine book has a fraction of the value Pizzorno imagines (see #8, above), the small profession will soon make an additional major contribution.

Yet the challenges for the naturopathic profession in securing a place of broad respect and inclusion in U.S. healthcare remain rather larger than many in the profession tend to say out loud. I offer this account of the profession at the moment of the AANP's 25th anniversary conference, warts and all, in the spirit of a sweeping assessment to support development of a health-creating strategy for the profession.

Resumes are useful in employment decisions. I provide this background so that you may understand what informs the work which you may employ in your own. I have been involved as an organizer-writer in the emerging fields......more

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